Abstract. In the pediatric population, scoliosis is classified into congenital, syndromic, idiopathic, and neuromuscular in aetiology. Syndromic scoliosis represents a wide range of systemic anomalies associated with scoliosis. The primary challenge for a clinician is to think beyond the scoliotic curve, as the underlying pathology is multisystemic. The aim of this review is to identify the systemic anomalies, associated with syndromic scoliosis. MEDLINE, EMBASE, and CINAHL databases were searched, dating from 1990–2020, relevant to the purpose of our study. Keywords used: “scoliosis”+ “syndrome” + “genetic”. Retrospective, prospective studies were included. Case reports that had fewer than 4 patients were not included. Delineating 60 articles, we found a total of 41 syndromes to be associated with scoliosis. Thoracic region was the most common level of scoliosis curve, being noted in 28 syndromes. Mental retardation, seizures, and ataxia were the commonly noticed CNS anomalies. VSD, ASD, and TGA were the anomalies associated with CVS; Hypotonia, rib and vertebral malformations were the most identified neuromuscular anomalies; pulmonary hypoplasia, renal agenesis, and strabismus were other associations. A multidisciplinary approach, involving spinal surgeons, paediatricians, geneticists, anesthesiologists, and allied health professionals, is vital for the best care of patients with syndromic scoliosis. The location of the scoliotic curve reflects the associated anomalies, as thoracic curvature is more closely linked with cardiac anomalies, while lumbosacral curvature is seen to be often linked with genitourinary anomalies. We hope that this article provides a clear overview of the systemic associations in syndromic scoliosis and thus, facilitates and streamlines the management protocol

We would like to present a rare case report describing a case in which new-onset tonic-clonic seizures occurred following an unintentional durotomy during lumbar discectomy and decompression. Unintentional durotomy is a frequent complication of spinal surgical procedures, with a rate as high as 17%. To our knowledge a case of new onset epilepsy has never been reported in the literature. Although dural rupture during surgery and CSF hypovolemia are thought to be the main contributing factors, one can postulate on the effects of anti-psychiatirc medication with epileptogenic properties. Amisulpride and Olanzapine can lower seizure threshold and therefore should be used with caution in patients previously diagnosed with epilepsy. However manufacturers do not state that in cases were the seizure threshold is already lowered by CSF hypotension, new onset epilepsy might be commoner. Finally, strong caution and aggressive post-operative monitoring is advised for patients with CSF hypotension in combination with possible eplieptogenic medication. Conflict of Interest: None. Source of Funding: None

Objective: To identify the demographics, risk factors and guidelines for treatment in a population of cerebral palsy (CP) children with fractures. Materials and Methods: One hundred and fifty children with CP received treatment for fractures from 1948 through 2000. To identify changes in demographics, patients treated before 1992 were compared to those treated after 1992. The latter group was matched by age and gender to a group of CP children without fractures and compared for: CP pattern, bone density, ambulatory status, presence of G-tube, weight for height-age Z score, surgical procedures during the previous year, presence of contractures in the proximity of the fracture and seizure medications. All data was analyzed statistically. Results: 67% of patients had a spastic quadriplegic pattern of CP and 89% were non-ambulatory; 78% of fractures occurred in lower limbs, 48% of the fractures were delayed in diagnosis, and 62% of patients showed osteo-penia. Children treated after 1992 had higher incidence of multiple fractures, less contractures, and less surgical procedures. The risk factors identified for increased fracture risk were: the use of seizure medication (p=.001), quadriplegic CP pattern (p=.005), decreased ambulatory status (p=.001), and lower bone density (p=.001). Most fractures were treated with soft bulky dressing. Conclusions: Ambulatory status and the presence of seizure medication are the greatest risk factors for fracture in children with CP. As a consequence, a low bone density occurs. Future research should focus on underlying fracture mechanisms and prevention

Introduction. In vitro studies have shown that low clearance metal-on-metal hip joints have the potential of reducing wear during the running-in phase [1]. However, cementless acetabular cup relies on press fitting into the acetabulum, which can generate non-uniform compressive stresses and non-uniform in vivo cup deformation [2, 3]. This could then lead to equatorial contact, resulting in higher wear and friction for a MoM bearing with low clearance. To benefit from low wear generated by low clearance and at the same time to avoid the potential of head seizure and high frictional torque caused by cup deformation, a deflection compensation acetabular cup (DefCom) has been developed based on the Birmingham Hip Resurfacing (BHR) device. The articulating sphere of the DefCom cup provides a low clearance bearing area, whilst the non-articulating sphere maintains the standard BHR clearance. The aim of this study was to evaluate the wear performance of the novel DefCom hip joint using a hip wear simulator. Materials and Methods. Five pairs of 50 mm DefCom devices were tested in a ProSim hip wear Simulator for 5 million cycles (MC) at a frequency of 1 Hz. The lubricant was new born calf serum with 0.2% sodium azide diluted with de-ionised water to achieve protein concentration of 20 mg/ml. The flexion/extension was 30° and 15° and the internal/external rotation was 10°. The force was Paul-type stance phase loading with a maximum load of 3 kN and a standard ISO swing phase load of 0.3 kN. Five standard 50 mm BHR devices were tested under the same testing conditions for comparison. Statistical analyses were performed at a 95% confidence level (CL) using the statistics function in Excel (Microsoft(r) Excel 2003). Results. Fig. 1 shows the cumulative volume loss against number of wear cycles for the DefCom and the BHR devices. Similar to the BHR device, the DefCom joints experienced relatively higher amount of material loss during the running-in phase from 0 to 1.0 Mc. However, the running-in wear rate for the DefCom device (0.23 ± 0.06 mm. 3. /MC) was much lower than that for the BHR device (0.72 ± 0.15 mm. 3. /MC). Steady state wear was achieved for all the joints from 1.0 to 5.0 MC. The steady state wear rate was 0.11 ± 0.03 mm. 3. /MC for DefCom and 0.18 ± 0.01 mm. 3. /MC for the BHR joints. Discussion. This study has shown that the DefCom acetabular cup has the potential to reduce the initial running-in wear by reducing the clearance at the contact area between the head and cup. The device also has the potential to avoid deformation induced head seizure and high frictional torque by maintaining a larger clearance at the periphery of the cup

Introduction: In vitro studies have shown that low clearance bearings have the potential to generate low wear. However, cementless acetabular cups are designed to be press fitted into the acetabulum, which could generate compressive stresses and non-uniform cup deformation during implantation. Deformation of the low clearance acetabular cups could also potentially lead to clamping or seizure of the joints and high frictional torque leading to implant failure. To obtain the benefit of low clearance and low wear, without compromising the tribological performance of the cup, a deflection compensation (DefCom) cup was designed. DefCom offers the benefits of low wear associated with low clearance components whilst reducing the risk of component seizure and high frictional torque due to component deformation. Aim: The study was conducted in order to evaluate the tribological performance of a DefCom acetabular cup. Materials and Methods: 50 mm diameter metal-on-metal DefCom hip resurfacing cups were used in this study. The components had an average clearance of 105±3 μm at the articulating sphere. Three of the cups were deformed plastically, along the ilial-ischeal column of the acetabulum. The degree of deformation was measured using the coordinate measuring machine, measuring the change in diameter of the cup in the direction of deformation. The cups were deformed on average by 65μm. The devices were tested in a ProSim hip wear Simulator for 5 million cycles. The lubricant was new born calf serum with 0.2% sodium azide diluted with de-ionised water to achieve protein concentration of 20 mg/ml. The flexion/extension was 30° and 15° with an internal/external rotation of ±10°. The force was Paul-type stance phase loading with a maximum load of 3 kN and a swing phase load of 0.3 kN, conducted at 1 Hz. Results: The DefCom and deformed DefCom components showed a similar bi-phasic wear pattern to that of the BHR devices. Showing a period of ‘running in’ wear up to 1 Mc and then a reduced wear rate during the steady state phase from 1 Mc onwards. The DefCom devices produced a wear rate of 0.24 mm3/Mc, whilst the deformed DefCom joints produced a wear rate of 0.48 mm3/Mc for the running-in phase. Steady state wear was achieved for all joints after 1 Mc. The average steady state wear (1.0–5.0 Mc) rate for the DefCom joints was 0.12 mm3/Mc, with 0.14 mm3/Mc for the deformed joints joint. The wear rate for the non-deformed DefCom device is lower than that generated by the BHR, which were 0.72 mm3/Mc and 0.18 mm3/Mc for the running-in and steady state wear, respectively. Conclusion: The study has shown that the DefCom acetabular cup has the potential to reduce the initial running-in wear by reducing the clearance at the contact area between the head and cup, whilst compensating for deformation that may occur during cup implantation

The classic Hill-Sachs lesion is a compression or impression fracture of the humeral head in occurrence with anterior glenohumeral instability. The true incidence is unknown but clearly increases with recurrent instability episodes. Recent peer-reviewed literature has highlighted the importance of addressing “significant” humeral and glenoid bone defects in the management of glenohumeral instability. Quantification of the “significance” of a Hill-Sachs lesion with regard to location, size, and depth in relation to the glenoid has helped guide indications for surgical management. Options for managing Hill-Sachs lesions include both humeral-sided techniques (soft tissue, bone, and/or prosthetic techniques) and also glenoid-sided techniques (bone transfers to increase glenoid width). The majority of significant acute or chronic Hill-Sachs lesions can be effectively managed without prosthetic replacement. Is a prosthetic surface replacement ever indicated for the management of Hill-Sachs lesions? The peer-reviewed literature is sparse with the outcomes of this treatment, and significant consideration must be given to both the age of the patient and the need for such management when other effective non-prosthetic options exist. In a patient with more than half of the humeral head involved after instability episodes (perhaps seizure or polytrauma patients), metallic surface replacement arthroplasty may be an option that could require less involved post-operative care while restoring range of motion and stability

Acute peri-operative blood loss warranting transfusion is a frequent consequence of major joint replacement (TJR) surgery. Significant peri-operative anemia can contribute to hypotension, dyspnea, coronary ischemia and other peri-operative medical events that can result in increased risk of peri-operative complications, readmissions and impair the patient's ability to mobilise after surgery resulting in a longer length of stay (LOS) and increase skilled nursing facility (SNF) utilization. The risks associated with allogeneic blood transfusions (ABT) administered to treat symptomatic peri-operative anemia are numerous and extend beyond the concerns of transmission of communicable disease (HIV, hepatitis, other). Patients receiving ABTs have been shown to have a longer hospital LOS, higher risk of infection, and higher mortality after TJR than those who do not require transfusion after surgery. As a result, many different pre-operative, peri-operative and post-operative strategies have been utilised to minimise peri-operative blood loss and transfusion need for patients undergoing TJR. Several studies have shown that the strongest predictor of the need for ABT in the TJR patient is the pre-operative hematocrit (Hct). As a result, all patients with unexplained pre-operative anemia should be evaluated for an underlying cause prior to elective TJR surgery. In recent years, focus has shifted towards peri-operative reduction of blood loss with the use of pharmacologic agents like tranexamic acid (TXA). These agents work by inhibiting fibrinolysis and activating plasminogen. Numerous studies have shown that TXA given IV, applied topically into the surgical wound or given orally have been shown to reduce peri-operative bleeding and ABT after both THA and TKR. Regardless of route of administration, all appear to be more efficacious and considerably more cost-effective in reducing the need for ABT than other methods discussed previously. Despite concerns about the potential increased thromboembolic risk in patients undergoing TJR, there does not appear to be any conclusive evidence suggesting an increased risk of venous thromboembolic disease (VTED) in TJR patients who receive peri-operative TXA. Although it may be unnecessary, many TJR surgeons still, however, avoid use of TXA in patients with a past history of VTED, stroke, coronary artery disease (including coronary stents), renal insufficiency, hypercoagulable state and seizure disorder. The use of topical TXA may be safer in some of these high risk patients since systemic absorption is minimal when administered via this route. Although the optimal method of administration (IV, topical, oral or combined) has not yet been determined based on safety, cost and reduction of need for ABT, incorporation of tranexamic acid into a blood conservation program is clearly the standard of care for all TJR programs that should nearly eliminate the need for ABT for patients undergoing TJR

Purpose of the study: From 1999 to 2004, 16 patients (25 hips) aged 2–9 years (average 5±3 years) were treated for spastic hips. The patients were diplegic (n=19 hips, 76%) and tetraplegic (n=6 hips, 24%). Pure pyramidal cerebral palsy patients with no history of seizure. Material and methods: The surgical plan was: femoral osteotomy, periacetabular osteotomy (San Diego), tenotomy of the adductors and psoas, anterior hip reduction as needed. Pain, range of abduction, Reimmer’s index and acetabular index were noted. Results: In the diplegic patients, outcome was good (70%), fair (23%), poor (7%). In tetraplegic patients, outcome was good (20%), fair (20%), poor (60%). Complications were avascular necrosis (n=1) and decubitus lesions (n=2)

A 35-year-old female (age 35Yrs) had primary MOM total hip arthroplasty (THA) in 2008. At 8 months this patient postoperatively developed headaches, memory loss, vertigo, and aura-like symptoms that progressed to seizures. At 18 months review, she complained of progressive hip pain, a popping sensation and crepitus with joint motion. This patient weighed 284lbs with BMI of 38.5. Radiographs revealed the cup had 55° inclination, 39° anteversion (Fig. 1). Metal ion concentrations were high (blood: Co=126 mcg/L, Cr= 64mcg/L). Revision was performed in November 2010 A dark, serous fluid was observed, along with synovitis. The implants were well fixed and the femoral head could not be removed; thus the stem was removed by femoral osteotomy. With the head fused on this femoral stem, for the 1. st. time it was possible to precisely determine the habitual patterns of MOM wear relative to her in-vivo function. We investigated (1) size and location of wear patterns and (2) signs of cup-stem impingement to help explain her symptoms developed over 32 months follow-up. The retrieved MOM was a Magnum™ with head diameter 50mm and 50×56mm cup (Biomet). This was mounted on a Taperloc™ lateralized porous-coated stem. Components were examined visually and wear damage mapped by stereo-microscopy, interferometry, CMM, SEM, and EDS. Main-wear zone (MWZ) areas were calculated using standard spherical equations. 1. and centroidal vectors determined. The head-cup mismatch was 427um with the cup revealing a form factor of 228um. The cup showed wear area of 1275mm² that extended up to the cup rim over 150°arc. The cup rim was worn thin over a 90° arc with loss of cup bevel. The head showed an elliptical wear area of 2200mm. 2. located centrally on the superior-medial surface (ellipsoidal ratio ×1.2). Compared to the hemispherical surface (50mm: hemi-area = 3927mm. 2. ), the worn area represented hemi-area ratio of 56%. The centroidal vectors measured 8° anterior and 24° superior to the head's polar axis (Fig. 2). Stripe wear damage revealed multiple impingement sites. SEM and EDS revealed stripes were contaminated by metal transfer from the stainless-steel instruments used at revision. The main impingement position was identified (Fig. 3) indicating the site of repetitive subluxations whereby the subluxing head thinned the cup, i.e. “edge wear”. Cup and head wear patterns corresponded well, reinforcing our definition of the MWZ locations in vivo. The femoral MWZ was centrally located superiorly and medially with respect to the polar axis of the femoral neck and head. The noted impingement position indicated this patient had experienced repetitive subclinical subluxations (RSS). 2. The taper inside the fused head may also have been a contributory factor that we cannot ignore. Nevertheless her excessive cup thinning was likely a result of a steep cup and considerable anteversion allowing the femoral head to sublux over the cup rim, thus thinning the cup and wearing the rim bevel, and producing MOM wear debris

Introduction: Locked posterior dislocations of the shoulder, with humeral head defects are rare injuries. It constitutes less than 2% of all posterior dislocations of the shoulder and 60% are misdiagnosed. There have only been a few articles describing the treatment of such injuries either by bone graft or Mc Laughlin’s procedure. Patients: The first patient is a 23 year-old who presented as a missed diagnosis three weeks after a seizure. The second is a 35 year-old male referred four weeks after a traumatic dislocation. The third is a 55 year-old, known epileptic, who was diagnosed on admission. CT scan revealed a locked humeral head against the posterior glenoid rim, with defects of 30%, 20% and 30% respectively. Treatment: All underwent reconstruction of the defect. The first using freeze-dried allograft, the second and third using iliac autograft. Results: Each patient was assessed using the Constant and Murley score. The first patient scored 76 points at 30 months, the second patient scored 95 at 12 months and the third scored 97 after 12 months post-operatively. Conclusion: Early diagnosis is important in management and prognosis of such injuries. Using bone graft in the reconstruction of the humeral head defect restores the normal anatomy, rather than distorting it by using McLaughlin’s procedure

Introduction: Cementless cup designs in metal-on-metal (MoM) hip resurfacing devices generally depend on a good primary press-fit fixation which stabilises the components in the early post-operative period. Pressfitting the cup into the acetabulum generates non-uniform compressive stresses on the cup and consequently causes non-uniform cup deformation. That in turn may result in equatorial contact, high frictional torque and femoral head seizure. It has been reported that high frictional torque has the potential to generate micromotion between the implant and its surrounding bone and as a result adversely affect the longevity of the implant. The aim of this study was to investigate the effects of cup deformation on friction between the articulating surfaces in MoM bearings with various clearances. Materials and methods: Six Birmingham Hip Resurfacing (BHR) devices with various clearances (80 to 306 μm) were tested in a hip friction simulator to determine the friction between the bearing surfaces. The components were tested in clotted blood which is the primary lubricant during the early post-operative period. The joints were friction tested initially in their pristine conditions and subsequently the cups were deflected by 25– 35 μm using two points pinching action before further friction tests were carried out. Results and Discussions: It has been reported that reduced clearance results in reduced friction. However, none of the previous studies have taken cup deflection into consideration nor have they used physiologically relevant lubricant. The results presented in this study show that for the reduced clearance components, friction was significantly increased when the cups were deflected by only 30 μm. However, for the components with higher clearance the friction did not change before and after deflection. It is postulated that the larger clearances can accommodate for the amount of distortion introduced to the cups in this study

The purpose of this retrospective study was to analyze the indications for spinal instrumentation, report the clinical features, operative details and outcome in 16 patients with active pyogenic spinal infection. Between January 1991 to October 1999, 81 patients with spontaneous pyogenic spinal infection were treated at the authors’ institution. Surgery (other than biopsy) was indicated in 24 patients for neurological deterioration, deformity or instability. Sixteen of these patients were treated with instrumentation in the presence of active spinal infection. Six patients underwent combined anterior and posterior procedures. 10 had a posterior procedure only. Outcomes assessed were control of infection, neurology, fusion, back pain and complications. At a mean follow up period of 26. 9 months, all surviving patients were free of clinical infection. None of the patients had neurological deterioration. All patients who had neurological deficit preoperatively improved by at least one Frankel grade. A solid fusion was achieved in 15 patients. 12/15 patients remained asymptomatic or had very little pain. The remaining 3 patients had mild to moderate back pain. The mean correction of the kyphotic deformity was 18. 92 degrees. Postoperative complications included bronchopneumonia, nonfatal pulmonary embolism and seizures in 3 patients. One patient developed progressive kyphosis despite instrumentation but eventually fused in kyphus. Given early recognition of pyogenic spinal infection, most cases can be managed non-operatively. Our results support that instrumented fusion with or without decompression may be used safely when indicated without the risk of recurrence of infection. Instrumentation facilitates nursing care and allows early mobilisation. For biomechanical reasons, a combined procedure is probably indicated for lesions above the conus. For lesions below the conus, we were able to achieve successful results with posterior approach only

Aims

Now that we are in the deceleration phase of the COVID-19 pandemic, the focus has shifted to how to safely reinstate elective operating. Regional and speciality specific data is important to guide this decision-making process. This study aimed to review 30-day mortality for all patients undergoing orthopaedic surgery during the peak of the pandemic within our region.

Objectives

To determine the morbidity and mortality outcomes of patients presenting with a fractured neck of femur in an Australian context. Peri-operative variables related to unfavourable outcomes were identified to allow planning of intervention strategies for improving peri-operative care.